Mathew Bishop, one of the authors of Philanthrocapitalism , last night told the audience of a Lancet debate packed into the grandeur of the Royal Society of Arts in London, that the rich—like Bill Gates, Warren Buffet, and Carlos Slim—could save the world.

Many in the audience were palpably horrified, believing exactly the opposite—that these rich bastards had made their fortunes on the backs of the poor and were now busy corrupting public bodies like the United Nations.

It was a wonderfully polarised debate entirely lacking nuance, and Richard Horton, editor of the Lancet, was right in his rollicking summing up to describe it as simply a beginning. It was, however, a debate that everybody there agreed was important and wasn’t really happening. Bishop was dismissed by his opponent, Dave McCoy, managing editor of the Global Health Watch, as a “neoliberal,” while Bishop accused McCoy of being a Marxist. Yet both complimented each other on contributing to the debate over the role of “philanthrocapitalists” in the modern world.

The title of the debate, which soon flowered into a clash of ideologies, was “What has the Gates Foundation done for global health?”which is also the title of a Lancet editorial. Bishop compared this to the famous Monty Python sketch “What have the Romans ever done for us?”

Apart from roads, medicine, education, wine, public health, peace, and public order it’s nothing, which is why the revolution must go ahead. Similarly Gates, according to the Lancet editorial, has given billions to global health, “challenged the world to think big and be more ambitious about what can be done to save lives in low income settings…added renewed dynamism, credibility, and attractiveness to global health…inaugurated an important new era of scientific commitment to global health…[and fostered] deep political commitment to health.”

So what’s the problem? McCoy acknowledged the importance of philanthropy and the contribution of Gates and aimed his attack less against Gates and more against “philanthrocapitalism” in general, recognising that Gates is the “poster child” of philanthrocapitalism.

But what is philanthrocapitalism? Is it anything new? There have since ancient times been rich people who gave to the poor, probably hoping to buy their way into heaven after a life of misdemeanours.

The difference, argued McCoy, is partly scale (although didn’t Rockefeller own a larger part of the US economy a hundred years ago than Gates has ever owned?) but more that these philanthrocapitalists are not simply giving money but are unaccountably pursuing their own agendas, insisting on the methods of business and markets, buying influence at the highest levels, corrupting public discourse, and pouring scorn on the flabbiness, slowness, and bureaucracy of more traditional organisations.

Further, they have achieved their wealth through dubious behaviour and through global markets that are increasing inequalities and leading to massive environmental damage. In other words, they are playing a prominent part in creating huge problems that worsen global health and then amusing themselves spending their money to ameliorate those problems.

The specific charges against the Gates Foundation are that it is undemocratic, unaccountable, and non-transparent, concentrating its resources on a few conditions rather than relating its spend to the global burden of disease, obsessed with technological fixes, and undermining health systems in many poor countries by attracting health workers and researchers into specific projects. Horton told the audience in summing up how Gates when he moved full time to the foundation had cancelled grants made with the intention of developing health systems.

The debate had an unhelpful tendency to roam into broad questions about capitalism generally, but there was agreement that the debate was a good thing and that philanthocapitalists must be made more accountable. McCoy and some members of the audience described the Gates Foundation as “wholly unaccountable,” but they were ignoring the power of accountability of the press.

As the Daily Telegraph has shown in the past few weeks with its exposure of corrupt practices in Britain’s parliament, accountability through the press can be very powerful. The Lancet is to be applauded both for the material it has published and holding the debate, but much more is needed.

In a day or two you will be able to listen to the whole debate by visiting the RSA website.

Competing interest: RS might be described as a crypto and small time philanthrocapitalist as he is director of the UnitedHealth Chronic Disease Initiative, which is funding centres in low and middle income countries to counter chronic disease. The Gates foundation has famously ignored chronic disease—perhaps in part because it is not amenable to technological fixes but needs wholesale change.